Abstract
STUDY QUESTION
Do adenomyosis phenotypes such as external or internal adenomyosis, as diagnosed by MRI, have the same clinical characteristics?
SUMMARY ANSWER
External adenomyosis was found ...more often in young and nulliparous women and was associated with deep infiltrating endometriosis, whereas, in contrast, internal adenomyosis was more often associated with heavy menstrual bleeding (HMB) but no differences were noted in terms of pain symptoms.
WHAT IS KNOWN ALREADY
Adenomyosis is characterized by the presence of endometrial glands and stroma deep within the myometrium, giving rise to dysmenorrhea, pelvic pain and menorrhagia. Various forms have been described, including adenomyosis of the outer myometrium (external adenomyosis), which corresponds to lesions separated from the junctional zone (JZ), and adenomyosis of the inner myometrium (internal adenomyosis), which is mostly characterized by endometrial implants scattered throughout the myometrium and enlargement of the JZ. Although the pathogenesis of adenomyosis is not clearly understood, several lines of evidence suggest that these two phenotypes could have distinct origins. The clinical presentation of different forms of adenomyosis in patients warrants further investigation.
STUDY DESIGN, SIZE, DURATION
This was an observational study that used data collected prospectively in non-pregnant patients aged between 18 and 42 years who had undergone surgical exploration for benign gynecological conditions at our institution between May 2005 and May 2018. Only women with a pelvic MRI performed by a senior radiologist during the preoperative work-up were retained for this study. For each patient, a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon in the month preceding the surgery. The women’s histories (notably their age, gravidity, history of surgery and associated endometriosis), as well as clinical symptoms such as the pain intensity, presence of menorrhagia and infertility, were noted.
PARTICIPANTS/MATERIALS, SETTING, METHODS
A pelvic MRI was performed in 496 women operated at our center for a benign gynecological disease who had provided signed informed consent. Of these, 248 women had a radiological diagnosis of adenomyosis. Based on the MRI findings, the women were diagnosed as having external and/or internal adenomyosis. The women were allocated to two groups according to the adenomyosis phenotype (only external adenomyosis vs only internal adenomyosis). Women exhibiting an association of both adenomyosis forms were analyzed separately.
MAIN RESULTS AND THE ROLE OF CHANCE
In all, following the MRI findings, 109 women (44.0%) exhibited only external adenomyosis, while 78 (31.5%) had only internal adenomyosis. The women with external adenomyosis were significantly younger (mean ± SD; 31.9 ± 4.6 vs 33.8 ± 5.2 years; P = 0.006), more often nulligravid (P ≤ 0.001) and more likely to exhibit an associated endometriosis (P < 0.001) compared to the women in the internal adenomyosis group. Moreover, the women exhibiting internal adenomyosis significantly more often had a history of previous uterine surgery (P = 0.002) and HMB (62 (80%) vs 58 (53.2%), P < 0.001) compared to the women with external adenomyosis. No differences in the pain scores (i.e. dysmenorrhea, non-cyclic pelvic pain and dyspareunia) were observed between the two groups.
LIMITATIONS, REASONS FOR CAUTION
The exclusive inclusion of surgical patients could constitute a possible selection bias, as the women referred to our center may have suffered from particularly severe clinical symptoms.
WIDER IMPLICATIONS OF THE FINDINGS
Further studies are needed to explore the pathogenesis by which these types of adenomyosis occur. This could help with the development of new treatment strategies specific for each entity.
STUDY FUNDING/COMPETING INTEREST(S)
none.
TRIAL REGISTRATION NUMBER
N/A.
Objective
To assess the risk of gestational hypertension (GH) and pre‐eclampsia (PE) during a second pregnancy after occurrence during a first pregnancy.
Design
Prospective cohort study.
Setting
...CONCEPTION is a French nationwide cohort study that used data from the National Health Data System (SNDS) database.
Methods
We included all women who gave birth for the first time in France in 2010–2018 and who subsequently gave birth. We identified GH and PE through hospital diagnoses and the dispensing of anti‐hypertensive drugs. The incidence rate ratios (IRR) of all hypertensive disorder of pregnancy (HDP) during the second pregnancy were estimated using Poisson models adjusted for confounding.
Main outcome measures
Incidence rate ratios of HDP during the second pregnancy.
Results
Of the 2 829 274 women included, 238 506 (8.4%) were diagnosed with HDP during their first pregnancy. In women with GH during their first pregnancy, 11.3% (IRR 4.5, 95% confidence interval CI 4.4–4.7) and 3.4% (IRR 5.0, 95% CI 4.8–5.3) developed GH and PE during their second pregnancy, respectively. In women with PE during their first pregnancy, 7.4% (IRR 2.6, 95% CI 2.5–2.7) and 14.7% (IRR 14.3, 95% CI 13.6–15.0) developed GH and PE during their second pregnancy, respectively. The more severe and earlier the PE during the first pregnancy, the stronger the likelihood of having PE during the second pregnancy. Maternal age, social deprivation, obesity, diabetes and chronic hypertension were all associated with PE recurrence.
Conclusion
These results can guide policymaking that focuses on improving counselling for women who wish to become pregnant more than once, by identifying those who would benefit more from tailored management of modifiable risk factors, and heightened surveillance during post‐first pregnancies.
Summary
Background
Hereditary angioedema attacks can be induced or worsened by oral contraceptive containing oestrogens.
Objectives
The purpose of this study was to assess the impact of progestin ...contraceptives on angioedema attacks.
Methods
We conducted a French retrospective, multi‐centre study of progestin contraception in women with non‐allergic angioedema, including hereditary angioedema type I, II and III and idiopathic angioedema. Patients were classified into four groups according to frequency of attacks. We evaluated the effects of progestin on the mean number of attacks and compared the number of patients in each group before and under progestin contraception. The influence of hormonal factors on the course of angioedema was also assessed.
Results
Fifty‐five women were included: mean age was 32.1 years (16–52) and mean follow‐up 32.4 months (SD:29). Fourteen women were classified as type I (25.4%), two as type II (3.6%) and 19 as type III (34%) and 20 were idiopathic (36%). Seventeen patients were taking a low dose progestin‐only pill (POP), 24 antigonadotropic progestins (AGP) and 14 both successively. Total or partial improvement was observed in 81.8% (45/55) of the patients and more frequently in those on an AGP agent (34 patients, 89.5%) than on POP (19 patients, 61.3%) (P = 0.013).
Conclusions & Clinical Relevance
This is the first study evaluating the interest of antigonadotropic progestin contraception in a series of women with non‐allergic angioedema. Progestins, especially antigonadotropic progestins, appear to convey a marked benefit in most cases. Antigonadotropic progestins could thus be recommended as adjuvant treatment in childbearing women with non‐allergic angioedema.
Breast cancer is the main risk associated with menopause hormone therapy (MHT). It is a hormone-dependent cancer. In postmenopausal women, about 80% of cases are estradiol receptor-positive. In ...cohort studies only estradiol receptor-positive breast cancers are promoted by MHT. Different levels of risk with estrogen-only treatment and combined treatment with estrogen + progestin are shown in randomized trials and observational studies. Several non-randomized studies show a lower risk with progesterone and retroprogesterone than with synthetic progestins. Progesterone and progestin are non-selective ligands for the progesterone receptor and bind also with other steroid receptors, with agonistic or antagonistic effects according to the structure of the molecule. Their half-life and metabolism are also different, progesterone being rapidly degraded with a short half-life. These aspects will be discussed in this review.
Abstract
STUDY QUESTION
Which factors are associated with low serum progesterone (P) levels on the day of frozen embryo transfer (FET), in HRT cycles?
SUMMARY ANSWER
BMI, parity and non-European ...geographic origin are factors associated with low serum P levels on the day of FET in HRT cycles.
WHAT IS KNOWN ALREADY
The detrimental impact of low serum P concentrations on HRT-FET outcomes is commonly recognized. However, the factors accounting for P level disparities among patients receiving the same luteal phase support treatment remain to be elucidated, to help clinicians predicting which subgroups of patients would benefit from a tailored P supplementation.
STUDY DESIGN, SIZE, DURATION
Observational cohort study with 915 patients undergoing HRT-FET at a tertiary care university hospital, between January 2019 and March 2020.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Patients undergoing single autologous blastocyst FET under HRT using exogenous estradiol and vaginal micronized progesterone for endometrial preparation. Women were only included once during the study period. The serum progesterone level was measured in the morning of the FET, in a single laboratory. Independent factors associated with low serum P levels (defined as ≤9.8 ng/ml, according to a previous published study) were analyzed using univariate and multivariate logistic regression models.
MAIN RESULTS AND THE ROLE OF CHANCE
Two hundred and twenty-six patients (24.7%) had a low serum P level, on the day of the FET. Patients with a serum P level ≤9.8 ng/ml had a lower live birth rate (26.1% vs 33.2%, P = 0.045) and a higher rate of early miscarriage (35.2% vs 21.5%, P = 0.008). Univariate analysis showed that BMI (P < 0.001), parity (P = 0.001), non-European geographic origin (P = 0.001), the duration of infertility (P = 0.018) and the use of oral estradiol for endometrial preparation (P = 0.009) were significantly associated with low serum P levels. Moreover, the proportion of active smokers was significantly lower in the ‘low P concentrations’ group (P = 0.002). After multivariate analysis, BMI (odds ratio (OR) 1.06 95% CI (1.02–1.11), P = 0.002), parity (OR 1.32 95% CI (1.04–1.66), P = 0.022), non-European geographic origin (OR 1.70 95% CI (1.21–2.39), P = 0.002) and active smoking (OR 0.43 95% CI (0.22–0.87), P = 0.018) remained independent factors associated with serum P levels ≤9.8 ng/ml.
LIMITATIONS, REASONS FOR CAUTION
The main limitation of this study is its observational design, leading to a risk of selection and confusion bias that cannot be ruled out, although a multivariable analysis was performed to minimize this.
WIDER IMPLICATIONS OF THE FINDINGS
Extrapolation of our results to other laboratories, or other routes and/or doses of administering progesterone also needs to be validated. There is urgent need for future research on clinical factors affecting P concentrations and the underlying pathophysiological mechanisms, to help clinicians in predicting which subgroups of patients would benefit from individualized luteal phase support.
STUDY FUNDING/COMPETING INTEREST(S)
No funding/no conflicts of interest.
TRIAL REGISTRATION NUMBER
N/A.
Following the Women's Health Initiative (WHI) publication in mid 2002, a drastic decrease in hormone therapy for postmenopausal women has been observed worldwide. Since 2007, the reported incidence ...in breast cancer has declined. Most authors have linked this decline to the reduction in hormone treatment. In this paper we discuss why these ecological observations are not fully convincing and focus on the importance of screening and variations in other risk factors to interpret this decline in breast cancer.
•The focus of the first menopause consultation is to address and provide answers to women's questions about menopause.•At menopause, improving lifestyle and nutrition, avoiding risk factors (notably ...smoking), and promoting physical activity could help limit the long-term impact of estrogen deficiency.•In women with moderate to severe vasomotor symptoms and in the absence of contraindications, it is recommended to prescribe menopausal hormone therapy (MHT) as first-line treatment.•For the management of genitourinary syndrome of menopause, vaginal treatment is recommended as first-line treatment.•In early postmenopausal women at low to moderate risk of fracture, it is recommended that MHT be proposed as first-line treatment to prevent osteoporosis.•To limit the excess risk of breast cancer associated with MHT, it is recommended that estradiol be combined with progesterone or dydrogesterone.•Current data do not allow the recommendation of an optimal duration of MHT, which must take into account its initial indication and its benefit–risk balance.
The aim of these recommendations is to set forth an individualized approach to the management of early postmenopausal women (i.e., within the first 10 years after natural menopause) covering all aspects of lifestyle and therapeutic management, with or without menopause hormone therapy (MHT).
Literature review and consensus of French expert opinion. Recommendations were graded according to the HAS methodology and levels of evidence derived from the international literature, except when there was no good-quality evidence.
The beginning of menopause is an ideal time for each woman to evaluate her health status by assessing her bone, cardiovascular, and cancer-related risk factors that may be amplified by postmenopausal estrogen deficiency and by reviewing her lifestyle habits. Improving lifestyle, including nutrition and physical activity, and avoiding risk factors (notably smoking), should be recommended to all women. MHT remains the most effective treatment for vasomotor symptoms but it could be also recommended as first-line treatment for the prevention of osteoporosis in early postmenopausal women at low to moderate risk for fracture. The risks of MHT differ depending on its type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. There is reasonable evidence that using transdermal estradiol in association with micronized progesterone or dydrogesterone may limit both the venous thromboembolic risk associated with oral estrogens and the risk of breast cancer associated with synthetic progestins. Treatment should be individualized to each woman, by using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of its benefit–risk balance. For bothersome genitourinary syndrome of menopause (GSM) symptoms, vaginal treatment with lubricants and moisturizers is recommended as first-line treatment together with low-dose vaginal estrogen therapy, depending on the clinical course. No recommendation of an optimal duration of MHT can be made, but it must take into consideration the initial indication for MHT as well as each woman's benefit–risk balance. Management of gynecological side-effects of MHT is also examined.
These recommendations are endorsed by the Groupe d'Etude sur la Ménopause et le Vieillissement hormonal (GEMVI) and the Collège National des Gynécologues-Obstétriciens Français (CNGOF).
BACKGROUND
Catamenial pneumothorax and thoracic endometriosis (TE) are still under diagnosed. The purpose of this study is to increase the diagnostic accuracy for these conditions in patients with ...spontaneous pneumothorax and to identify their risk factors.
METHODS
We conducted a retrospective study on all consecutive women of reproductive age referred to our Centre for surgical treatment of spontaneous pneumothorax between July 2000 and January 2009.
RESULTS
The study population comprised 156 premenopausal women of whom 49 (31.4%) had catamenial and/or TE-related pneumothorax. Over a quarter of these 49 patients had a previous history of recurrent thoracic or scapular catamenial pain. They experienced their first pneumothorax episode at an older age (mean ± SD) (34.0 years ± 6.7) than women with idiopathic pneumothorax (28.7 ± 6.1 years, P < 0.001). Pelvic endometriosis was found in 51% of women with catamenial and/or TE-related pneumothorax. After adjustment for confounding factors by multiple logistic regression analysis, the results show that, infertility odd ratio (OR) = 4.21, 95% confidence interval (CI) = 1.28–13.88 and a history of pelvic surgery with a uterine procedure and/or uterine scraping (OR = 2.85, 95% CI = 1.12–7.26) were the strongest predictors of catamenial and/or TE-related pneumothorax.
CONCLUSIONS
Infertility and uterine procedures are significantly associated with catamenial and/or TE-related pneumothorax. Scapular or thoracic pain during menses often precedes the occurrence of pneumothorax and is highly specific for the diagnosis of TE. Our results suggest that in women with pelvic endometriosis, these symptoms should be systematically investigated for an earlier diagnosis of TE.
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